Taking aim at unseen wounds of war: AOA, AACOM join federal initiative

Instilled with the values of fortitude and personal sacrifice, military personnel in war zones are trained to ignore their own emotions, minor ailments and physical discomfort as they brave oftentimes horrific scenarios. As a result, many men and women in the armed forces leave active duty with undiagnosed psychological problems and subtle but ultimately debilitating physical injuries and conditions. While individuals who are severely wounded in action receive prompt medical treatment, those with post-traumatic stress disorder, post-combat depression and mild traumatic brain injury often go undetected.

Because more than 70% of military service members who return from Iraq and Afghanistan seek care outside of the Military Health System and Veterans Affairs medical facilities, the White House has launched the clinical component of the federal Joining Forces initiative to raise health professionals’ awareness of the frequently unseen wounds of war.

The AOA and the American Association of Colleges of Osteopathic Medicine (AACOM) are among some 40 health care organizations taking part in the Joining Forces clinical campaign, which kicked off in January during meetings at the White House and at Virginia Commonwealth University (VCU) in Richmond. On the campus of the VCU School of Medicine, First Lady Michelle Obama challenged medical school deans, as well as other health care leaders, to better educate students, physicians and other clinicians on the medical and mental health needs of post-9/11 military personnel and veterans.

“If you have a visible wound, that’s an easy diagnosis,” says AOA Trustee Michael K. Murphy, DO, a U.S. Navy veteran who is spearheading the AOA’s efforts in the Joining Forces campaign. “But if you weren’t hit directly by an IED [improvised explosive device] but saw someone get blown up right in front of you or your vehicle was lifted off the ground a couple of feet and bounced around a lot, these situations create problems that surface after you return home.”

Given osteopathic medicine’s focus on primary care and the underserved, the AOA must play a key role in ensuring that military personnel and veterans, especially those who live far from VA facilities, receive the care they need in their communities, Dr. Murphy says.

During its July meeting in Chicago, the AOA House of Delegates passed a resolution directing the AOA to urge practicing DOs to accept Tricare, which covers active duty and retired military personnel and their families, and to promote the development of continuing medical education related to combat-induced health problems.

Initial steps

The AOA’s first step has been to inform osteopathic physicians about existing resources on caring for military personnel and veterans. One of these resources is a military health history pocket card developed by the Department of Veterans Affairs that provides specific questions to ask of patients who are serving or have served in the military:

• Tell me about your military experience.
• When and where do/did you serve?
• What do/did you do while in the service?
• How has military service affected you?
• Did you see combat, enemy fire or casualties?
• Were you or a buddy wounded, injured or hospitalized?
• Did you ever become ill while you were in the service?
• Were you a prisoner of war?

The AOA distributed hard copies of the pocket card during the House meeting last month and will do the same during OMED 2012 in October in San Diego.

Another online resource, the Defense and Veterans Brain Injury Center’s website, describes in detail the frequently hidden problem of blast-related traumatic brain injury. A third resource, the website of the National Center for PTSD, offers physicians a wealth of information on diagnosing and treating patients for a disorder affecting more than 10% of military service members who saw combat in Iraq or Afghanistan.

In addition to sharing resources with the profession on Osteopathic.org and in an article by Dr. Murphy in JAOA—The Journal of the American Osteopathic Association, the AOA is partnering with state osteopathic medical associations and osteopathic specialty societies to get the word out about the medical needs of military service members and veterans. Traveling to meetings of these societies, Dr. Murphy gives presentations on combat-related health issues.

Dr. Murphy will also moderate a town hall meeting on veterans’ and service members’ health care needs during OMED 2012. Scheduled for Tuesday, Oct. 9, the hour-long program will include a presentation by Meredith L. Perry, DO, a Navy flight surgeon who was seriously injured in Afghanistan.

The director of medical education for Bluefield (W. Va.) Regional Medical Center, Dr. Murphy is working to make sure that all interns and residents at Bluefield receive training in recognizing and treating patients for military-related medical conditions. Through the Association of Osteopathic Directors and Medical Educators (AODME), he is urging other DMEs to do the same.

Collaborative commitment

Twenty-six osteopathic medical schools and four branch campuses have signed onto the Joining Forces pledge of support.

According to an analysis of one school, first- and second-year students receive insufficient direct instruction in diagnosing and addressing common combat-induced conditions. “Even with today’s extremely dense course schedules, several hours can still be devoted to the diagnosis and management of PTSD, TBI and depression,” wrote Murray R. Berkowitz, DO, MPH, an associate professor at the Georgia Campus—Philadelphia College of Osteopathic Medicine in Suwanee, whose curriculum he studied.

Most osteopathic medical schools do provide students some instruction related to traumatic brain injury and PTSD, AACOM contends. AACOM is gathering information from each school to see what instructional materials can be shared.

One major component of AACOM’s Joining Forces endeavor is to encourage all osteopathic medical schools to hold military health care educational programs on Veterans Day. “Traumatic brain injury, PTSD and musculoskeletal problems related to military personnel are all important issues that could be taught on that day,” says Tyler C. Cymet, DO, AACOM’s associate vice president for medical education. “An AACOM working group is developing two hours of content that colleges can use, including three cases for students to work through and a detailed PowerPoint presentation. We may also have a videoconference with military-related content.”

Like the AOA, AACOM has aggregated resources related to military health care on its website. In addition, the 2013 joint annual meeting of AACOM and the AODME, scheduled for April in Baltimore, will include several sessions related to the Joining Forces initiative.

Another AACOM working group is looking at the musculoskeletal problems that plague military personnel and veterans to come up with osteopathic manipulative treatment protocols, says U.S. Army veteran Marc B. Hahn, DO, who chairs AACOM’s Joining Forces Advisory Board. “Osteopathic medical schools are uniquely qualified to address many of those musculoskeletal issues in both active-duty military personnel and veterans,” says the senior vice president for health affairs and dean of the University of New England College of Osteopathic Medicine in Biddeford, Maine.

After 10 years of war in Iraq and Afghanistan, more than 1 in 6 veterans have PTSD or depression, notes Dr. Hahn, who served for eight years as the chief of pain medicine for Walter Reed Army Medical Center. “Medical students, interns, residents and practicing physicians need to be aware that these issues are prevalent in the great men and women who serve this country.”

cschierhorn@osteopathic.org